CV drugs Flashcards
G PACMAN
CYP3A4 inhibitors that interact with simvastatin & lovastatin:
Grapefruit
Protease inhibitors
Azole antifungals
Cyclosporine, cobicistat
Macrolides (except azithromycin)
Amiodarone
Non-DHP CCB’s (dilt, verap)
Nitro-Bid
Long acting nitrate
Nitroglycerin ointment 2%
Admin: dosed BID 6 hrs apart w/ 10-12 hr nitrate-free interval
Thalitone
Thiazide diuretic
Chlorthalidone
MONA-GAP-BA
M
Morphine sulfate -> pain relief
reserved for unacceptable pain/discomfort
has been shown to diminish antiplatelet effects
Dose: 2-5mg IV Q5-30min PRN
Beta Blockers: Beta 1 selective agent characteristics
Boxed warning: do not DC abruptly
CI: severe bradycardia, AV block
Warnings:
- can worsen hyper or hypoglycemia & mask hypoglycemic sx in diabetic pts
- caution in asthma/COPD (bronchospasm)
ADE:
- Bradycardia
- Fatigue/Depression
- Hypotension
- Impotence
- can exacerbate Raynaud’s (cold extremities)
Notes:
- beta 1 selective agents safest BB for asthma/COPD
- take without regard to food (except metoprolol -> take with food)
- Metoprolol tartrate IV: PO = 1:2.5
Simvastatin 10mg
Low intensity
How long after PDE-5i’s can nitrates be given?
Avanafil (Stendra): 12hrs
Sildenafil (Viagra): 24hrs
Vardenafil: 24hrs
Tadalafil (Cialis): 48hrs
Vasotec IV
ACEi
Enalaprilat
DHP CCB class characteristics
MOA: inhibit Ca ions from entering vascular smooth muscle & myocardial cells -> peripheral arterial vasodilation -> decreased systemic resistance (SVR) & BP
Warnings:
- Hypotension
- do not use nifedipine IR for chronic or acute BP reduction in non-pregnant adults -> profound hypotension, MI, death
ADE:
- Tachycardia/palpitations
- HA
- flushing
- peripheral edema
- gingival hyperplasia (less than Non DHP)
Notes:
- used to prevent Raynaud’s (cold, blue fingers)
Fibrinolytic characteristics
CI:
- active bleed
- recent stroke
- severe uncontrolled HTN
ADE: bleeding
Monitor:
- Hgb
- Hct
- signs of bleeding
Integrilin
GP 2b/3b RA
Eptifibatide
ADE: bleeding, thrombocytopenia
reversible blockade- platelet function recovers in 4-8hrs
Lovastatin 20mg
Low intensity
Inspra
K sparing diuretic
Eplerenone
Non-DHP CCB class characteristics
MOA: same as DHP CCB’s but selective for myocardial tissue
Use: control HR in certain arrhythmias
- sometimes also used for HTN & angina
Warnings:
- may worsen HF symptoms
- bradycardia
ADE:
- edema
- constipation
- gingival hyperplasia
Cardizem, Tiazac
Non-DHP CCBs
Diltiazem
Ziac
Bisoprolol/HCTZ
Calan SR
Non-DHP CCB
Verapamil
Beta Blockers: Beta 1 selective agents
Atenolol (Tenormin)
Esmolol (Brevibolc)
Metoprolol Tartrate (Lopressor)
Metoprolol Succinate ER (Toprol XL)
Zestril, Prinivil
ACEi
Lisinopril
Avapro
ARB
Irbesartan
Toprol XL
Beta 1 selective BB
Metoprolol succinate ER
Lipitor
Atorvastatin
Coreg
Nonselective BB & alpha-1 blocker
Carvedilol
Fluvastatin 20-40mg
Low intensity
Hyzaar
Losartan/HCTZ
Atorvastatin 40-80 mg
High intensity
Statins: lipid panel monitoring
lipid panel @ baseline, 4-12 weeks after initiation, yearly thereafter
Benicar HCT
Olmesartan/HCTZ
Exforgel
Valsartan/Amlodipine
MONA-GAP-BA
A (MONA)
Aspirin
Non-enteric coated, chewable ASA 162-325mg immediately
maintenance dose 81-162 daily indefinitely
Effient Dosing
LD: 60mg PO
MD: 10 mg PO daily
Effient
P2Y12
Prasugrel
BW: BLEEDING
- not recommended in pts > 75
- stop at least 7 days prior to surgery
- avoid use if CABG likely
CI:
- active bleed
- hx of TIA or stroke
Warnings:
- bleed risk
- TTP
ADE: bleed
Notes:
- Only indicated for ACS managed with PCI
- Dispense in original container
Rosuvastatin 5-10 mg
Moderate intensity
Simvastatin 20-40mg
Moderate intenstiy
Beta 1 selective agent w/ NO dependent vasodilation
- agent
- characteristics
Nebivolol (Bystolic)
Same as other beta1 selective agents PLUS
- contraindicated in severe liver impairment
- ADE: nausea, inc TGs, dec HDL
Benicar
ARB
Olmesartan
sprue-like enteropathy: severe, chronic diarrhea w/ substantial weight loss; can occur months-years after initiation
Brillinta
P2Y12
Ticagrelor
BW:
- bleeding
- do not exceed 100mg ASA daily d/t reduced ticagrelor effectiveness
- avoid use if CABG likely
- stop 5 days before surgery
CI:
- active bleed
- Hx of intracranial hemorrhage
Warnings:
- bleed risk
- TTP
ADE:
- bleeding
- dyspnea
Which statins have fewer DDI
Rosuvastatin
Pravastatin
Plavix Dosing
LD: 300-600 mg PO
- 600 for PCI
MD: 75 mg PO daily
Adalat CCB, Procardia XL
DHP CCB
Nifedipine ER
Diovan HCT
Valsartan/HCTZ
Welchol
Colesevelam
Bile acid sequestrant
CI: bowel obstruction
ADE: constipation, ABD pain, bloating, gas, inc TG
NitroMist, Nitrolingual
Short acting nitrate
Nitroglycerin TL spray
Potassium Sparing Diuretic Class Characteristics
MOA: compete with aldosterone at receptors in the nephron -> inc excretion of Na and water while conserving K
CI:
- hyperkalemia
- severe renal disease
ADE:
- hyperkalemia
- increased SCr
- Dizziness
DDI:
- can decrease Li clearance -> toxicity
Beta Blocker MOA
MOA: competitively block beta 1 and/or beta 2 adrenergic receptors -> decreased HR and myocardial contractility
Bystolic
Beta 1 selective BB w/ NO dependent vasodilation
Nebivolol
Vasotec
ACEi
Enalapril
MONA-GAP-BA
O
Oxygen
indicated for patients w/ SaO2 sat < 90% & pts in respiratory distress
Statin equivalent doses
Remember: Pharmacists Rock AT Saving Lives and PReventing Fatty Deposits
Pitavastatin: 2mg
Rosuvastatin: 5 mg
Atorvastatin: 10mg
Simvastatin: 20mg
Lovastatin: 40mg
Pravastatin: 40mg
Fluvastatin: 80mg
HTN Classification:
SBP 130-139 OR DBP 80-89
Stage 1 HTN
Pravachol
Pravastatin
G PACMAN
Significant CYP3A4 inhibitor DDI with simvastatin & lovastatin
- Grapefruit
- Protease inhibitors (CI)
- Azole antifungals (CI)
- Cyclosporine, Cobicistat (alt -> Ros, Ato respectively)
- Macrolides, except azithromycin (CI)
- Amiodarone (caution)
- Non-DHP CCBs (decrease dose)
Zetia
Ezetimibe
inhibits cholesterol absorption
ADE: myalgia
Lipid effects:
- dec LDL 18-23%
Aldactone
K sparing diuretic
Spironolactone
Unique characteristics:
- blocks androgen -> endocrine ADEs
- CI: Addison’s disease (adrenal insufficiency)
- ADE: gynecomastia, breast tenderness, impotence
MONA-GAP-BA
G
GP 2b/3a RAs
Eptifibatide
Tirofiban
Lopressor
Beta 1 selective BB
Metoprolol Tartrate
Statin lipid effects
decrease LDL ~ 20-55%
decrease TG ~ 10-30%
increase HDL ~ 5-15%
Drugs that increase BP
Amphetamines & ADHD meds
Cocaine
Decongestants (pseudoephedrine, phenylephrine)
ESAs
Immunosuppressants (cyclosporine)
NSAIDs
Systemic steroids
Lotrel
Benazepril/Amlodipine
Activase
Fibrinolytic
Alteplase
MOA: tissue plasminogen activator
ACE inhibitor class characteristics
MOA: block conversion of angiotensin I to angiotensin II -> dec vasoconstriction & aldosterone secretion
Boxed Warning:
- do not use in pregnancy (teratogenic)
Contraindications:
- Hx of angioedema with RAASi use
- do not use within 36h of Entresto
Warnings:
- angioedema
- hyperkalemia
ADE:
- cough
- hyperkalemia
- inc SCr
- hypotension
MONA-GAP-BA
P
P2Y12 inhibitors
Clopidogrel
Prasugrel
Ticagrelor
Zocor
Simvastatin
Plavix
P2Y12
Clopidogrel
BW: test for CYP2C19 genotype (poor metabolizers will not see full effectiveness from this prodrug)
CI: active bleed
Warnings:
- bleed risk (stop 5d before planned surgery)
- do not use with omeprazole or esomeprazole
- Thrombotic thrombocytopenic purpura (TTP)
ADE:
- bleed risk
Tenormin
Beta 1 selective BB
Atenolol
Non-selective beta blockers
Propranolol (Inderal)
Nadolol (Corgard)
Same characteristics as B1 blockers PLUS
- additional use: portal hypertension
- not preferred in asthma / COPD
ARB class characteristics
MOA: block angiotensin II from binding to receptors on vascular smooth muscle -> prevents vasoconstriction
Safety/ADE/Warnings same as ACE’s except:
- Less cough
- less angioedema
- no washout period with Entresto
Inderal
Nonselective BB
Propranolol
Statins that should be taken in the evening
Fluvastatin IR
Lovastatin (Altoprev) XR
Simvastatin (Zocor)
Ranexa
Anti-anginal agent
Ranolazine
Use: substitute for or addition to BB in SIHD maintenance treatment
CI: strong CYP3A4 inhibitors/inducers
Warnings:
- QT prolongation
- acute renal failure when CrCl < 30
ADE: dizziness, HA, constipation, nausea
Notes: not for acute treatment of chest pain
Rosuvastatin 20-40 mg
High intensity
Zestoretic
Lisinopril/HCTZ
Aquazide H, Hydrocot
Thiazide diuretic
Hydrochlorothiazide
Lotensin
ACEi
Benazepril
Fluvastatin 40 mg BID / 80mg XL
Moderate intensity
Lovaza
Omega 3 Acid Ethyl Esters
Fish oil
Warning: caution with hx of HSR to fish or shellfish
ADE: burping, dyspepsia, taste perversion, inc bleed risk
Lipid effects:
- Dec TG up to 45%
- can inc LDL up to 44%
Trandate
Nonselective BB & alpha-1 blockers
Labetalol
preferred agent in pregnancy
Brevibloc
Beta 1 selective BB
Esmolol
injection only
HTN Classification:
SBP > 140 OR DBP > 90
Stage 2 HTN
Niacor, Niaspan
Niacin (aka nicotinic acid, vit B3)
Warnings
- rhabdomyolysis
- hepatotoxicity
- Lab abnormalities (inc BG & uric acid)
ADE:
- flushing
- pruritus (itching)
- vomiting
- diarrhea
- hyperglycemia
- gout
Admin: take with food
ER formulation (Niaspan) preferred due to less flushing & hepatotoxicity
Lipid effects:
- inc HDL~15-35%
Norvasc
DHP CCB
Amlodipine
Safest CCB in HFrEF if one must be used
Statin contraindications
breast feeding
liver disease
concurrent use of strong CYP3A4 inhibitors (simva & lova)
Repatha
Evolocumab
PCSK9i
Admin: SC every 2 weeks or monthly
ADE: injection site reactions
Lipid effects:
- dec LDL ~ 60%
Isordil Titradose
Long acting nitrate
Isosorbide dinitrate
Statin ADE
myalgia/myopathy
hepatotoxicity
Lovastatin 40 mg
Moderate intensity
Isodur
Long acting nitrate
Isosorbide mononitrate
IR tab: dosed BID, 7 hrs apart
ER tab: daily AM dosing
HTN Classification:
SBP < 120 AND DBP < 80
Normal
Cardene IV
DHP CCB
Nicardipine
Lopid
Gemfibrozil
Class: Fibrate
CI: severe liver disease, gallbladder disease
Warnings: inc risk of myopathy when taken with statins
ADE:
- Dyspepsia
- inc LFTs (dose related)
DDI:
- can inc effects of sulfonylureas and warfarin
Lipid effects:
- dec TG ~20-50%
- can inc LDL when TG are high
Nitroglycerin clinical characteristics
CI: do not use with PDE-5i’s
ADE:
- HA
- flushing
- syncope
- hypotension/dizziness
Praluent
Alirocumab
PCSK9i
Admin: SC every 2 weeks or monthly
ADE: injection site reactions
Lipid effects:
- dec LDL ~ 60%
MONA-GAP-BA
B
Beta blockers
Metoprolol or carvedilol preferred
contraindications:
- decompensated HF
- cardiogenic shock
- HR < 45 bpm
MONA-GAP-BA
A (GAP)
Anticoagulants
LMWH (enoxaparin, dalteparin)
UFH
Bivaliruden
UFH & Bivaliruden preferred in STEMI
MONA-GAP-BA
N
Nitrates
0.4mg SL NTG every 5 minutes x 3 doses
if symptoms persist -> IV NTG
Do not use IV NTG if:
- SBP < 90 mmHg
- HR < 50 bpm
- PDE-5 inhibitor use
HTN treatment in pregnant patients
Preferred drugs:
- Labetalol
- Nifedipine ER
Avoid:
- ACEs & ARBs
Preeclampsia:
- daily low dose ASA after 1st trimester in high risk pts (prior HTN, renal disease, diabetes)
Cozaar
ARB
Losartan
Vascepa
Icosapent ethyl
Fish oil
Warning: caution with hx of HSR to fish or shellfish
ADE: burping, dyspepsia, taste perversion, inc bleed risk
Admin: take with food
Lipid effects:
- Dec TG up to 45%
- DOES NOT inc LDL
Beta blocker DDIs
- enhance hypoglycemic effects of insulin & SU’s
- caution with other drugs that lower HR (diltiazem, verapamil, digoxin, clonidine, amiodarone)
Maxzide
Triamterene/HCTZ
(K sparing / Thiazide diuretic)
Nitrostat
Short acting nitrate:
Nitroglycerin SL tablets
Store in original amber glass bottle
Non-selective BB & alpha 1 blockers
Carvedilol (Coreg)
Labetalol (Trandate)
Same as B1 selective agents PLUS
- CI: severe hepatic impairment
- Warning: intraoperative floppy iris syndrome
- ADE: edema, weight gain
Notes
- take carvedilol with food to decrease rate of absorption -> less ortho hypo
ReoPro
GP 2b/3a RA
Abciximab
ADE: bleeding, thrombocytopenia
irreversible blockade- platelet function recovers in 24-48 hrs
only recommended in ACS patients receiving PCI +/- stent
Aggrastat
GP 2b/3b RA
Tirofiban
ADE: bleeding, thrombocytopenia
reversible blockade- platelet function recovers in 4-8hrs
GoNitro
Short acting nitrate
Nitroglycerin SL powder
Statin Warnings
Higher risk for muscle damage with:
- high dose
- old age
- + niacin, gemfibrozil, or CYP3A4 inhibitor
Diabetes:
- may increase A1C & fasting glucose
TNKase
Fibrinolytic
Tenecteplase
Corgard
Nonselective BB
Nadolol
Tenoretic
Atenolol/Chlorthalidone
Carvedilol ER:IR conversion
3.125mg IR = 10mg ER
Altoprev
Lovastatin
Nitro-Dur
Long acting nitrate
Nitroglycerin transdermal patch
Admin: wear for 12-14hrs, off for 10-12hrs; rotate sites
Preferred stable angina maintenance treatment in HFrEF
Isosorbide dinitrate + Hydralazine
Accupril
ACEi
Quinapril
Long acting nitrates notes
Require a 10-12 hr nitrate-free interval to reduce tolerance
Patch: wear for 12-14hrs, off for 10-12hrs; rotate sites
Ointment: dosed BID 6 hrs apart w/ 10-12 hr nitrate-free interval
Pravastatin 10-20mg
Low intensity
Antara, Tricor, Trilipix
Fenofibrate, Fenofibric Acid
Class: Fibrate
CI: severe liver disease, gallbladder disease
Warnings: inc risk of myopathy when taken with statins
ADE: inc LFTs (dose related)
DDI:
- can inc effects of sulfonylureas & warfarin
Lipid effects:
- dec TG ~20-50%
- can inc LDL when TG are high
Crestor
Rosuvastatin
Altace
ACEi
Ramipril
Pravastatin 40-80 mg
Moderate intensity
Pitavastatin 1-4mg
Moderate intensity
Calcium Channel Blocker DDIs
- Caution with other drugs that reduce HR (BB, digoxin, clonidine, amiodarone)
- CCBs are major substrates of CYP3A4, caution with strong inducers & inhibitors
- NDHP CCBs can reduce lovastatin & simvastatin metabolism
MONA-GAP-BA
A (BA)
ACE inhibitor
start within first 24hrs & continue indefinitely in pts w/ LVEF < 40%, HTN, diabetes, or stable CKD.
use ARB if pt is ACE intolerant
do not use IV ACE within the first 24 hrs due to risk of hypotension
HTN Classification:
SBP 120-129 AND DBP < 80
Elevated BP
Brilinta Dosing
LD: 180 mg PO
MD: 90mg PO BID x 1 year then 60mg PO BID
Atorvastatin 10-20 mg
Moderate intensity
Thiazide diuretic class characteristics
MOA: inhibit Na reabsorption in the distal convoluted tubule -> inc excretion of Na, Cl, K, and water
CI: sulfonamide allergy
ADE:
- Decreased K, Mg, Na
- Increased Ca, UA, LDL, TG, BG
DDI:
- NSAIDs decrease thiazide effectiveness (water retention)
- Thiazides decrease Li clearance -> toxicity
- not effective in CrCl < 30
- take in AM to avoid nocturia
